Figure: 28 TAC §3.3837(c)(2)
Long-Term Care Insurance
Claim Denials Reporting Form
FOR THE STATE OF TEXAS
For the Reporting Year of _____________
Due: No later than June 30 annually for the preceding calendar year
Company Name: _______________________________________________________
Company Address: _____________________________________________________
Company NAIC Number: ________________________________________________
Contact Person: _______________________ Phone Number: __________________
Line of Business: Individual Group
The purpose of this form is to report all long-term care claim denials under in force long-term care
insurance policies. "Claim" means a request for payment of benefits under an in-force policy regardless of
whether the benefit claimed is covered under the policy or any terms or conditions of the policy have been
Indicate the manner of reporting by checking one of the boxes below.
Per Claimant - counts each individual who makes one or a series of claim requests
Per Transaction - counts each claim request
"Denied" means a claim that is not paid for any reason other than for failure to meet the waiting period or
because of an applicable preexisting condition. It does not include a request for payment that is in excess
of the applicable contractual limits.
1 Total Number of Long-Term Care Claims Reported
2 Total Number of Long-Term Care Claims Denied/Not Paid
3 Number of Claims Not Paid due to Preexisting Condition
4 Number of Claims Not Paid due to Waiting (Elimination) Period
5 Net Number of Long-Term Care Claims Denied for Reporting
Purposes (Line 2 Minus Line 3 Minus Line 4)
6 Percentage of Long-Term Care Claims Denied of Those Reported
(Line 5 divided by Line 1)
7 Number of Long-Term Care Claims Denied due to:
8 • Long-Term Care Services Not Covered under the Policy2
9 • Provider/Facility Not Qualified under the Policy3
10 • Benefit eligibility Criteria Not Met4
11 • Other5
1. The nationwide data may be viewed as a more representative and credible indicator where the
data for claims reported and denied for your state are small in number.
2. Example: home health care claim filed under a nursing home only policy.
3. Example: a facility that does not meet the minimum level of care requirements or the licensing
requirements as outlined in the policy.
4. Examples: (i) a benefit trigger not met; (ii) certification by a licensed health care practitioner not
provided; (iii) no plan of care.
5. Examples: duplicate submission, incomplete claim submission, advance billing.
Form Number LHL564(LTC)